Echo Guidelines Aim to Minimize Cancer Therapy Toxicity

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WEDNESDAY, Jan. 4, 2012 (MedPage Today) — The death last year of 51-year-old Kara Kennedy of a heart attack put the spotlight on cardiovascular damage from cancer treatments. Kennedy had survived lung cancer nearly a decade before, and speculation linked chemotherapy as a contributing factor in her death.

As a result of the heightened awareness, two echocardiography societies are developing guidelines to optimize the use of the imaging modality before and during cancer treatment to minimize cardiac damage.

Because patients are living longer following cancer treatment, they are more at risk for cardiovascular disease. In fact, the leading cause of death among breast cancer survivors in remission is heart disease, said Juan Carlos Plana, MD, co-director of the Cardio-Oncology Center at the Cleveland Clinic and chair of the guideline writing committee.

The guideline committee, made up of members of the American Society of Echocardiography and the European Association of Echocardiography, will focus on standard echo techniques such as 2D, Doppler, and contrast-enhanced echo, but it also will evaluate newer techniques such as 3D and strain echo, which are emerging as important tools to monitor cardiac function.

Strain imaging allows physicians to identify the performance of each segment of the heart. "We have learned that toxicity is not a global phenomenon, that the entire heart is not compromised," Plana told MedPage Today in an interview.

So, a global indicator like ejection fraction could miss specific toxicity, he said. Strain imaging, on the other hand, assesses each segment of the heart separately, even color-coding the segments, which would give physicians a much more accurate indication of cardiotoxicity as a result of cancer therapy.

Strain imaging also can pick up cardiac toxicity damage earlier than measuring ejection fraction can. "We have been pleasantly surprised at strain imaging's ability to prognosticate a future drop in cardiac function," he said. "We have shown that strain imaging gives information three months in advance of a drop in ejection fraction."

This type of "early warning" opens the opportunity to treat patients sooner than traditionally would be possible with cardioprotective therapies," Plana said.

One of the finer points the writing group will tackle is when imaging should begin after therapy. Right now, there is no consensus on this issue. But every patient should have a baseline echocardiogram, Plana said.

Other data are emerging showing that cardiotoxicity starts at different times for different cancer therapies. "We will look at all the data and make recommendations for imaging protocols based on when we know we can first see the damage from cardiotoxicity and when we know we can make a difference with cardioprotective therapies," Plana told MedPage Today.

There are several limitations to strain imaging, he said, including the fact that it is based on 2D imaging. "If your data is inadequate to begin with, the strain imaging data will be equally as inadequate."

Also, there is a learning curve, said Plana, who's been working with the technology for half a dozen years. And there are problems with one vendor's software talking with another vendor's software. "We cannot use information across vendors, and overcoming this limitation is at the forefront of the American Society of Echocardiography agenda this year," he said.

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